Conditions for excellence in teaching in medical education: The Frankfurt Model to ensure quality in teaching and learning

Background: There is general consensus that the organizational and administrative aspects of academic study programs exert an important influence on teaching and learning. Despite this, no comprehensive framework currently exists to describe the conditions that affect the quality of teaching and learning in medical education. The aim of this paper is to systematically and comprehensively identify these factors to offer academic administrators and decision makers interested in improving teaching a theory-based and, to an extent, empirically founded framework on the basis of which improvements in teaching quality can be identified and implemented. Method: Primarily, the issue was addressed by combining a theory-driven deductive approach with an experience based, “best evidence” one during the course of two workshops held by the GMA Committee on Personnel and Organizational Development in Academic Teaching (POiL) in Munich (2013) and Frankfurt (2014). Two models describing the conditions relevant to teaching and learning (Euler/Hahn and Rindermann) were critically appraised and synthesized into a new third model. Practical examples of teaching strategies that promote or hinder learning were compiled and added to the categories of this model and, to the extent possible, supported with empirical evidence. Based on this, a checklist with recommendations for optimizing general academic conditions was formulated. Results: The Frankfurt Model of conditions to ensure Quality in Teaching and Learning covers six categories: organizational structure/medical school culture, regulatory frameworks, curricular requirements, time constraints, material and personnel resources, and qualification of teaching staff. These categories have been supplemented by the interests, motives and abilities of the actual teachers and students in this particular setting. The categories of this model provide the structure for a checklist in which recommendations for optimizing teaching are given. Conclusions: The checklist derived from the Frankfurt Model for ensuring quality in teaching and learning can be used for quality assurance and to improve the conditions under which teaching and learning take place in medical schools.


Background
Curriculum designers, department heads and policy makers have many options regarding medical education, some of which they are very possible unaware. Knowledge of general organizational and administrative aspects could help in the selection of targeted and effective interventions. Accordingly, the German Council of Science and Humanities lists numerous aspects pertaining to teaching in its 2012 guideline for evaluating university medical schools and institutions [1]. The main categories are structure and organization of the academic study program, professionalism of the teaching, quality assurance of the teaching, and teaching infrastructure. The World Federation for Medical Education (WFME) [2] views the learning environment as significant for the evaluation of medical programs. In the Charta guter Lehre [https:// www.stifterverband.org/charta-guter-lehre], drafted under the encouragement of the Stifterverband für die Deutsche Wissenschaft, there are extensive recommendations to create conditions for excellence in higher education. This document contains many best-practice examples, but provides no concrete references to medical education. Such connections are of great importance when meeting the challenges faced in university medicine, for instance, the rivalry between academic teaching and providing medical care, the high financial costs associated with the studies of medicine, the necessity for strictly structured curricula, and the great demands placed by society on medical graduates (reliability, patient safety, etc.). For all of the works cited above there is no comprehensive system that shows how these organizational aspects work or can be controlled. It appears particularly important to consider the different degrees to which conditions can be shaped or influenced to optimally use any potential flexibility. Two models are of help when classifying quality-influencing conditions: Euler and Hahn's [3] model describing the conditions for teaching and the quality assurance model proposed by Donabedian [4], which was originally developed for the healthcare sector. The first model identifies six categories of university-relevant conditions, described below. Donabedian's model encompasses the quality dimensions of structure, process and outcome, and has the advantage of describing variables that are relatively concrete and verifiable. Its disadvantage is that the correlations between structure, process, and outcome are not considered. Furthermore, it is without question that in educational settings the interactions between those directly involved in the teaching and learning processes must be included. These participants include students with their different interests, motives and varying degrees of prior knowledge, as well as instructors with their varying methods and teaching abilities. The complex interaction between them and the setting can be captured well by situativity theory [5] and other similar approaches [6], [7], [8] since relevant complex (nonlinear and multiphase) interactions in a situation are emphasized. Of importance for higher education is the multidimensional model of successful teaching put forth by Rindermann [9] whose elements can be assigned to the dimensions identified by Donabedian and even show the relationships and interactions between these elements. Curriculum designers, department heads and key policy makers carry a social responsibility for educational programs [10], [11]. This circle of people should therefore be familiar with the basic conditions that promote teaching and learning, primarily given that in the case of medicine there is, in addition to the classic academic rivalry between teaching and research, serious competition with the provision of medial care [12]. The aim of this paper is to develop a model for medical education with which the relevant organizational and administrative conditions related to teaching and learning can be described within the context of increasing healthcare demands. Based on this model, recommendations are intended for effective and efficient creation of conditions conducive to teaching and learning.

A Working Group of the German Association for Medical
Education's Committee on Personnel and Organizational Development [https://gesellschaft-medizinische-ausbildung.org/aktivitaeten/ausschuesse/personal-und-organisationsentwicklung/mitglieder.html held two workshops in 2013 and 2014 in Munich and Frankfurt to address the issue of favorable and unfavorable conditions for teaching and learning. The workshops were conducted in the form of moderated discussions. To provide structure following intensive debate, only the two models best suited to medical education were drawn upon and applied. All of the participants had many years of experience in medical education and had completed either advanced post-licensure training in psychology, or medical education and medicine. Prior to the first workshop the participants filled out a matrix regarding the organizational aspects and general conditions at their own medical schools which foster or impede learning. This matrix was based on the model by Euler and Hahn [3] and covered six categories of general conditions relevant to higher education (see below). The positive and negative conditions based on experience were compiled in the first workshop and discussed. Potential problems and solutions were then identified. Since it became clear during the first workshop that Euler and Hahn's model did not establish connections to teaching, Rindermann's multidimensional model for teaching outcomes [9] was integrated into Euler and Hahn's model during the second workshop. As a result, the interactions of the people participating in the teaching and learning processes and their relationship to the outcome were taken into account. Subsequently, empiricallybased approaches were sought for the positive and negative conditions. The results of this paper form the basis for a checklist to facilitate quality assurance and the optimization of teaching at medical schools.
The Frankfurt Model of conditions to ensure the quality of teaching and learning The Frankfurt Model 1 of conditions to ensure the quality of teaching and learning (see figure 1) synthesizes two already established models. The categories in the model described by Euler und Hahn [3] can be described as follows: 1. Organizational structure/medical school culture: regulations, rules and measures can, among other things, steer department procedures (e.g. general philosophy, organigrams) [13]. This also applies to the commonly shared unwritten assumptions, values and expectations (culture) of those on the faculty and staff. Based on this, many different interventional measures to optimize teaching can present themselves. 2. Regulatory frameworks: here it must be ascertained whether there is room to maneuver within the existing framework and how this flexibility can be used most meaningfully. For example, the use of pilot study program clauses and the introduction of controls to stop any additional applicants from suing for admission fall under this category. 3. With curricular requirements curriculum designers have the greatest opportunity to set a course of direction or initiate a change. They can, for instance, ensure that the curricular content in natural sciences and the clinical subjects is vertically integrated. Further opportunities exist in that a specific educational philosophy (e.g. POL) becomes anchored in the medical school or that focus is placed on a specific area (e.g. general practice). 4. Qualification of teaching staff: the quality of teaching is a critical factor in an educational setting [14], [15].
Since the balance between teaching and other responsibilities can vary dramatically among instructors, medical schools have the challenge of pragmatically "dosing out" qualification measures as they are needed. 5. The category material and personnel resources encompasses classroom spaces and teaching materials (e.g. devices for practical tutorials and simulators), audio/visuals for the various teaching and learning methods, and the availability of sufficiently qualified staff for planning, organization and implementation.
In terms of materials, the critical question must be asked if new acquisitions always lead to better educational outcomes [16], [17]. 6. The final category of Euler and Hahn's model describes time constraints. This includes not only the time instructors spend in the classroom, but also the time available to prepare and evaluate class sessions and to develop teaching. For students this means the time needed to prepare for and follow-up on class sessions and the time spent traveling to and from class.
In order to include the actors and the teaching/learning process and the outcome of this process, a second model, Rindermann's multidimensional model of successful teaching [9], was selected and integrated into the first model. According to this model an optimal outcome is the goal of academic teaching -despite all the difficulties of quantifying it. Measurable outcomes, such as exam scores, do not automatically allow for conclusions to be drawn about teaching quality in a particular subject [18], [19], [20], [21]. Other indicators of good teaching such as raising interest in the learning material, strengthening self-efficacy, and a professionalization of the student are also not simple to measure or analyze. For instance, at the beginning of their studies students already possess knowledge about different areas of interest that influence their learning behavior [22]. In addition, their skills, motivation and attitudes toward the program and its organizational and administrative aspects can be influenced [23], [24], [25]. Note must also be taken of conditions that are not connected with the teaching/learning process at hand or that are not within the instructor's control (e.g. fairness variables, such as heat, overfull classes, acoustics [9], [26]).

Checklist of conditions conducive to teaching and learning
Recommendations for medical schools were articulated by the Working Group based on the Frankfurt Model (above) detailing the conditions conducive to teaching and learning. These recommendations are supported by the empirical evidence available at this time and are listed in the form of a checklist in attachment 1.
The recommendations contained in the checklist are not based on systematic literature research. This checklist should therefore be gradually expanded and updated.

Conclusion
The organizational and administrative aspects of academic study programs exert significant influence on teaching and learning. For this reason decision makers at medical schools need to know which conditions are relevant and how they can be optimally shaped or influenced to improve teaching. With the Frankfurt Model's ability to identify program aspects that foster quality in teaching and learning, a model has been developed that captures important university-relevant conditions [1], [2], [3], [4] and also incorporates the complexity of the teaching and learning process [5], [8]. Based on this model a checklist of recommendations for good practice has been drafted to enable medical schools to analyze and optimize, where needed, the conditions under which teaching and learning take place at their institutions. This paper also offers a theoretical foundation for recommendations to ensure quality in teaching and learning at medical schools.